Inspection on 21/03/07 for Westholme

This inspection was carried out on 21st March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westholme 05/03/08

Westholme 17/05/06

Westholme 25/01/06

Westholme 24/08/05

Westholme 20/12/04

Westholme 15/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Westholme 24/28 Victoria Road St Annes On Sea Lancashire FY8 1LE Lead Inspector Lesley Plant Unannounced Inspection 10:00 21 and 22 March 2007 st nd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westholme Address 24/28 Victoria Road St Annes On Sea Lancashire FY8 1LE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01253 727114 Mrs Vivien Perry vacant post Care Home 35 Category(ies) of Dementia (35) registration, with number of places Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 35 Date of last inspection 17th May 2006 Brief Description of the Service: Westholme is registered to accommodate 35 service users with dementia. The property is large; with accommodation spread over three floors. The home is located near to the centre of St Annes, close to local services and amenities. Mrs V Perry is the registered provider and has owned the home for over 23 years. Westholme has been undergoing an extension and refurbishment programme, with the aim of improving the facilities and increasing the number of registered places available. A number of new bedrooms are now provided and changes to the kitchen and dining room are underway. Registration has recently increased to 35. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days and looked at all the key National Minimum Standards plus supervision arrangements for staff. The last full inspection was carried out in May/June 2006, with a follow up visit in August 2006 to monitor progress with requirements and recommendations. At the time of this inspection there were 19 service users resident at the home. The manager was not on duty, however the deputy manager was able to provide necessary information and documentation. Discussions took place with, the deputy manager, care coordinator, two care assistants and one relative. Records and documentation were viewed and a tour of the building was carried out. Time was spent talking to and observing people living at the home. All the service users have various degrees of cognitive impairment therefore some conversations were brief and limited. There is a manager in post, however they are not yet registered with the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Some improvements have been made to the physical environment. Three new en suite bedrooms have been built and new flooring laid in other bedrooms. A new laundry facility is now in place and the newly built kitchen is almost complete. The role of the key worker has become established and staff are clear about their responsibilities. Good progress is being made with NVQ training. Four staff have achieved NVQ level 2 or 3 and four more staff are working towards the level 2 award. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 6 What they could do better: The care planning system needs to improve; to include clear directions as to how needs should be met. This guidance for staff and regular reviews will ensure that changing needs are recognised and responded to. Care plans could also include details of service users’ interests and a guide for staff regarding how best to engage individuals on a one to one basis. The use of bed rails must be risk assessed and regularly reviewed in order to ensure that this is a safe and appropriate aid to be used. The policy regarding abuse must be revised, to reflect locally agreed procedures and all staff should undergo some training in this area. The kitchen does not comply with standards set out by the environmental health agency. The completion of the new kitchen will address this problem. Regular maintenance checks will help to ensure that Westholme is a safe and pleasant place to live. A random inspection in August 2006 found that correct recruitment procedures were not being followed and this is still the case. Staff must not commence duty prior to the necessary checks being completed as this may put service users at risk. Medication arrangements would be strengthened if any, “when required” medication, was accompanied by clear directions regarding under what circumstances this should be given. This was raised at a previous inspection and had been addressed, however the records viewed do not now contain this vital information. Medication records should also include a photograph of the service user. Progress with NVQ training should be monitored; in order to achieve 50 of staff being qualified. The induction programme for new staff should meet the Skills for Care standards and all staff should undertake training regarding dementia. Staff would also benefit from regular formal supervision. Quality assurance systems should include gaining feedback from stakeholders such as relatives. A number of these areas for improvement have been raised at a previous inspection. The change in management arrangements and the focus on building work appears to be delaying progress in addressing the issues raised. The registered provider is required to supply the CSCI with an improvement plan. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. The assessment process helps to ensure that service users are only admitted to Westholme if their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a detailed assessment format in place, which provides opportunity to gather adequate information prior to admitting a new service user. The records regarding an individual recently admitted to the home were viewed. A full assessment of needs had been carried out, which included an assessment of mobility and pressure care. A pre discharge assessment from hospital was also available. During discussions the husband of this resident confirmed that he had been involved in providing information and that the admissions process had gone smoothly. Prospective residents and their relatives are invited to visit Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 10 the home prior to admission in order to view the facilities and meet the residents and staff. Intermediate care is not provided at Westholme. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. Care planning does not clearly identify how needs are to be met or include details of when non regular medication should be administered, meaning that changing needs may not be identified or responded to. Privacy and dignity are promoted during the day-to-day work of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files for four service users were examined. Since the last key inspection a new manager has taken up post and has introduced new care planning documentation. The files viewed show that reviews take place approximately each month for most, but not all service users. The key worker, who writes an overview of the main events for the previous month, carries out this review. Care plans contain a lot of useful information regarding the needs of the individual and address such areas as mobility, falls, pressure care and mental Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 12 health. However there is little detail of how needs are to be met. The care planning documentation is in effect an assessment and not a plan, detailing how the needs identified are to be met by staff. For one person the care plan states that they are at high risk of both falls and pressure sores and that they can be aggressive, but there is no detail to guide staff in addressing these needs. For another person the care plan states that they can be resistive when receiving personal care, but again no detail of how to manage this. This must be improved, as it is difficult to see how changes can be recorded and addressed. For each identified need there should be clear guidance as to how this will be met by staff. This will be particularly important as numbers increase, when robust care planning systems will be vital. Care plans should also address activities and interests giving details of how best to engage service users. Bed rails are currently in use for two individuals. No risk assessments were in place. This is essential as the use of bed rails can pose risks. These must be regularly reviewed as part of the care plan. This had been raised at the last key inspection and a follow up visit showed that although not being reviewed, risk assessments had been carried out. However risk assessments such as this do not appear to be part of the current system of care planning. Staff keep good daily records, which include issues regarding health care and an overview of how each person has been, including eating and sleeping. Records are kept of all health care appointments, such as GP visits and chiropody. Each service user has their weight monitored and records are kept. A physiotherapist visits the home each week to conduct a group exercise session. Pressure relief aids are available and staff have a good understanding of how to maintain good health in this area. A senior member of staff, the care coordinator, has responsibility for overseeing the arrangements for medication within the home. Only senior staff administer medication and they have undertaken training in this area. A pharmacist has also carried out some basic training with all of the staff team. The medication administration records viewed were appropriately completed, with a minor error being addressed by the care coordinator. Medication not contained within the monitored dosage system is being dated on opening as previously advised. Details of “when required” medication should include the exact circumstances particular to the individual, of when medication should be administered. For example, how an individual would indicate if in pain and required pain relief medication. This had previously been in place and was part of the individuals’ care plan, but is no longer being addressed. In addition, it is recommended that although a photo of each person is available, there should be a photo kept within the medication file. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 13 Privacy and dignity are addressed with all new staff during the induction period. Screening is provided in the double bedrooms. During the inspection staff were observed responding gently and sensitively to service users, such as when guiding a person to the bathroom or assisting an individual to eat their meal. All the residents were nicely dressed, with staff clearly recognising the importance of this in relation to maintaining dignity. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. The provision of more one to one time with service users would improve the activities programme at the home. Visitors are made welcome and homely meals are provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a weekly activity programme, with details of the activities for each day posted on the lounge doors and notice board. The different lounge areas allow for different activities to take place in different areas of the home. These include music, reading materials, games such as skittles, hairdressing, films and a weekly exercise session carried out by a physiotherapist. Trips out are mainly arranged during the summer months. Improvements still need to be made in this area, as during the inspection staff were seen working hard carrying out the necessary routine tasks, however there was little evidence of staff spending individual time with service users. The manager should continue to monitor the activities programme and look for ways for service users to Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 15 receive one to one attention, other than for practical care. It is recommended that care plans include details of service users interests and a guide for staff regarding how best to engage individuals on a one to one basis. The relative spoken to confirmed that he is always made welcome and can visit at any time. Drinks are provided to visitors and staff were observed to be friendly and welcoming. Service users can receive visitors in their bedroom or in one of the communal areas. The planned increase in dining space will allow more choice and privacy for chatting to visitors. The service users at Westholme all have a diagnosis of dementia resulting in various degrees of cognitive impairment. Relatives usually take responsibility for financial affairs. The relative spoken to confirmed that he is kept informed of important matters and that he has been involved in discussions regarding the care of his relative. There is a three-week menu in place. The cook is aware of individual likes and dislikes and any particular food, which can’t be eaten for health reasons. At present the main meal consists of a set menu, with alternatives being provided on request. It is advised that once the new kitchen is operational that menus be reviewed with a view to providing a choice of meals at each mealtime. A number of service users require help with meals and staff were observed providing this support in a gentle and sensitive manner. A new kitchen is being built and there are plans to increase the size of and renew the dining room. Due to the building work, there are temporary dining arrangements in place. Issues regarding the kitchen and dining facilities are addressed under standard 19 of this report. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Arrangements for handling complaints are in place. Policies, practice and staff training need improvement in order to fully promote the protection of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place, which gives a clear timeframe within which concerns would be responded to. There have been no complaints made directly to the home since the last key inspection. The relative spoken to was confident that any concerns raised would be responded to. The Commission for Social Care Inspection were notified of some concerns and these were looked into in August 2006. The outcome being that recruitment practices needed to improve and a new cooker was required in the kitchen. A separate report is available at the CSCI office. The owner of the home had also addressed another concern, regarding the manager bringing a small dog into the office. There are procedures in place to ensure that concerns are taken seriously and responded to. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 17 The new manager of the home has drawn up new policies and procedures regarding abuse and protection. Although a copy of the No Secrets in Lancashire guidance is available the policy regarding responding to an abuse allegation is misleading and does not adhere to local multi agency agreements. This should be amended to include clear guidance regarding reporting all such concerns to the local authority who act as the lead agency in these matters. It is also advised that more detail of how to respond to physical or verbal aggression should be included in individual care plans. Some staff have undertaken training regarding vulnerability, abuse and protection and arrangements should be made for all the team to undertake training in this area. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. The kitchen does not comply with the requirements of the environmental health agency, meaning that the welfare of service users may be compromised. Service user areas of the home are clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last key inspection found major shortfalls regarding the provision of a safe, homely environment. The majority of these concerns have been addressed and when the new kitchen and dining room are completed the home will be greatly improved. Three new en suite bedrooms have been built and new flooring has been fitted in a number of the other bedrooms. There are plans to renew and Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 19 re site the conservatory, which has been agreed as part of the application to increase the number of service users at the home. The past year has seen major changes to the building and it is important that routine maintenance issues addressed. Regular maintenance checks must take place and records need to be kept. These checks should include checking window restrictors. A recent visit by the environmental health agency raised major concerns regarding standards of cleanliness in the kitchen. This area is old and outdated making thorough cleaning difficult. It is anticipated that the new kitchen will resolve these problems and the registered provider has confirmed that completion of work in this area is imminent. Until the standards of the environmental health agency are met the home continues to provide a poor environment. The registered provider must provide the CSCI with confirmation of building control approval regarding the new conservatory and the changes to the ground floor bedroom, previously the office. The home employs staff with specific responsibility for laundry and domestic tasks. The laundry facilities have been renewed and are much improved. The service user areas of the home are clean, with no offensive odours. Staff were observed following infection control procedures by wearing protective clothing for certain tasks. The basic core programme of staff training includes food hygiene and health and safety training, which address some aspects of infection control which also included in the induction of new staff. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. The home is staffed appropriately and NVQ training is promoted, providing opportunity for staff to develop further skills in their work. Recruitment procedures are poor and do not promote the protection of service users. A more thorough induction process and training in dementia would increase staff competence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 19 service users were resident at Westholme at the time of this inspection. Numbers have been temporarily reduced to allow for major building work to be carried out. During the visit there were five care staff (including the deputy manager) on duty during the day, four care staff during the evening and three staff on waking night duty. Rotas show that these staffing levels are regularly maintained, with the exception of sometimes having just two staff on waking night duty. Separate cleaning and kitchen staff are employed. These staffing arrangements appear adequate for the current service users and will be increased as the home admits more residents. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 21 NVQ training is being given a stronger focus at the home. There are 18 care staff plus the manager; this includes day and night staff. Four staff have achieved NVQ level 2 or above and four staff are working towards level 2 or three awards. The deputy manager has commenced the level four award and has also gained the NVQ assessors award. Having a qualified NVQ assessor at the home means that qualification training for care staff can be more readily accessed and achieved. It is important that this progress continues. The recruitment files for three recently appointed staff were viewed. Documentation includes an application form, record of interview and copies of training certificates. Two files showed that two references had been gained and Criminal Records Bureau (CRB) disclosures were available. However for one staff member, in post for just three days, there was only one reference and no CRB disclosure or confirmation that the Protection of Vulnerable Adults list had been checked. A random inspection in August 2006 found that correct recruitment procedures were not being followed and this is still the case. Staff must not commence duty prior to the necessary checks being completed. New staff work alongside experienced staff during their induction period. Induction records are maintained, with each element being signed by a senior member of staff. Staff training continues to improve. A training matrix for the staff team is in place, giving a good overview of the skills of the team and allowing for any gaps in training to be addressed. Staff who have completed core training such as food hygiene, first aid, moving and handling and health and safety are clearly identified. The majority of staff have attended these courses, with a number of staff due to attend programmes during the next six weeks. Good links have been established with a training provider, in relation to this core training. Not all staff have completed training regarding dementia and this should be addressed. Training in dementia should be considered vital core training for all care staff at the home. The last key inspection found that new staff received an induction file containing the Skills for Care Induction standards, although this induction process was not fully established. The induction process has again changed, with senior staff working through a checklist of information and confirming competency in certain areas. All new staff should undergo an induction, which meets the Skills for Care Induction standards as well as having an introduction to the home. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. Changes to systems and ways of working have not ensured that best practice is always promoted. Improvements to quality assurance systems will help to ensure that service user and relatives’ views are gained. Staff training supports the health and safety of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 23 The home has seen a number of changes during the past 18 months, with three different managers during this time. The current manager has been in post for seven months and is still to apply for registration with the Commission for Social Care Inspection. The manager is experienced in the field of social care and has previously held management posts. There is also a deputy manager and a care coordinator, plus senior care assistants. Monthly management meetings take place, involving the manager, deputy manager, care coordinator and the owner of the home. The two care staff spoken to were aware of the lines of accountability and said that there is always a senior member of staff to go to for advice. Management changes have resulted in changes to certain systems such as care planning, risk assessment, medication and staff training. The manager should ensure that these systems are effective and appropriate for the home. An application for registration must be received by the CSCI. In the past questionnaires were distributed to relatives, in order to gain feedback about the quality of the service provided. This quality monitoring should be reintroduced and consideration given to other quality assurance and quality monitoring activities. For the majority of people living at the home, a relative will take responsibility for finances. A record is kept of expenditure, such as hairdressing costs, incurred by each service user, which is then paid by the relative on behalf of the individual. In general personal spending money is not kept at the home. A safe is available, although the home does not normally keep valuables on behalf of service users, this could be provided if required. The deputy manager is working hard to provide formal supervision to care staff. A six monthly supervision/skills assessment is carried out, which identifies areas for improvement and any training needs. At present not all care staff receive regular supervision, which should be taking place at least six times a year for each staff member. Staff meetings are held approximately every three months. New staff work alongside a more experienced member of the team. The core-training programme includes training in safe working practices and records show that most staff have completed these courses. Records viewed included; water temperatures, servicing of the stair lift, checking of electrical appliances, checking of the gas installation, the testing of fire equipment and the record of fire drills. The fire service has requested that a record is kept of testing the emergency lighting system and the deputy manager confirmed that the best way to do this would be agreed with the fire service. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP7 Regulation 15 13 Timescale for action Care plans must show how needs 30/05/07 are to be met and must be regularly reviewed. The use of bed rails must be risk 30/04/07 assessed and regularly reviewed. (Not met from previous inspection.) The abuse policy must be reviewed to incorporate the correct reporting and recording protocols as stated in ‘No Secrets’ (Not met from previous inspection) 30/04/07 Requirement 3. OP18 13 4. 5. OP19 OP19 23 23 The kitchen must comply with standards set out by the environmental health agency. The registered provider must provide the CSCI with confirmation of building control approval regarding the new conservatory and the changes to the ground floor bedroom, previously the office. DS0000009752.V331159.R01.S.doc 30/05/07 30/05/07 Westholme Version 5.2 Page 26 6. OP19 23 Regular maintenance checks must take place, any problems quickly addressed and records kept. These checks should include checking window restrictors. Recruitment information and documents specified in schedule 2 must be obtained prior to staff commencing duty. (Not met from previous random inspection.) The manager must apply for registration with the CSCI. 30/04/07 7. OP29 19 and schedule 2 05/04/07 8. OP31 9 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP9 Good Practice Recommendations Medication records should include a photograph of the service user. Directions for “when required” medication should include specific detail of when the medication should be administered. Service users should receive more one to one attention, other than for practical care. It is recommended that care plans include details of service users interests and a guide for staff regarding how best to engage individuals on a one to one basis. Staff should undergo training regarding abuse and protection. Progress with NVQ training should be monitored; in order to achieve 50 qualified staff. DS0000009752.V331159.R01.S.doc Version 5.2 Page 27 3. OP12 4. 5. OP18 OP28 Westholme 6. OP30 All staff should complete the core-training programme, which should include dementia training. Induction training should meet Skills for Care standards. 7. OP30 8. 9. OP33 OP36 Quality assurance systems should include gaining feedback from stakeholders such as relatives. All care staff should receive supervision at least six times a year. Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westholme DS0000009752.V331159.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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